Aims-To examine whether a multifaceted intervention among older at-risk drinking primary care patients reduced at-risk drinking and alcohol consumption at 3 and 12 months. Design-Randomized controlled trial.Setting-Three primary care sites in southern California.Participants-Six hundred thirty-one adults aged ≥ 55 years who were at-risk drinkers identified by the Comorbidity Alcohol Risk Evaluation Tool (CARET) were randomly assigned between October 2004 and April 2007 during an office visit to receive a booklet on healthy behaviors or an intervention including a personalized report, booklet on alcohol and aging, drinking diary, advice from the primary care provider and telephone counseling from a health educator at 2, 4 and 8 weeks.Measurements-The primary outcome was the proportion of participants meeting at-risk criteria, and secondary outcomes were number of drinks in past 7 days, heavy drinking (4 or more drinks in a day) in the past 7 days and risk score.. Conclusions-A multifaceted intervention among older at-risk drinkers in primary care does not reduce the proportions of at-risk or heavy drinkers, but does reduce amount of drinking at 12 months.

Background/Objectives The quality of care for geriatric conditions remains poor. The Assessing Care of Vulnerable Elders (ACOVE)-2 model (case finding, delegation of data collection, structured visit notes, physician and patient education, and linkage to community resources) improves the quality of care for geriatric conditions when implemented by primary care physicians (PCPs) or by nurse practitioners (NPs) co-managing care with an academic geriatrician. However, it is unclear whether community-based PCP-NP co-management can achieve similar results. Design Case study. Setting Two community-based primary care practices. Participants Patients > 75 years who screened positive for at least one condition: falls, urinary incontinence (UI), dementia, and depression. Intervention The ACOVE-2 model augmented by NP co-management of conditions. Measurements Quality of care by medical record review using ACOVE-3 quality indicators (QIs). Patients receiving co-management were compared with those who received PCP care alone in the same practices. Results Of 1084 screened patients, 658 (61%) screened positive for > 1 condition; 485 of these patients were randomly selected for chart review and triggered a mean of 7 QIs. A NP saw approximately half (49%) for co-management. Overall, patients received 57% of recommended care. Quality scores for all conditions (falls: 80% versus 34%; UI: 66% versus 19%; dementia: 59% versus 38%) except depression (63% versus 60%) were higher for patients seen by a NP. In analyses adjusted for gender, age of patient, number of conditions, site, and a NP estimate of medical management style, NP co-management remained significantly associated with receiving recommended care (p<0.001), as did the NP estimate of medical management style (p=0.02). Conclusion Compared to usual care using the ACOVE-2 model, NP co-management is associated with better quality of care for geriatric conditions in community-based primary care.

Purpose Most health outcome measures for chronic diseases do not incorporate specific health goals of patients and caregivers. To elicit patient-centered goals for dementia care, we conducted a qualitative study using focus groups of people with early-stage dementia and dementia caregivers. Methods We conducted 5 focus groups with 43 participants (7 with early-stage dementia and 36 caregivers); 15 participants were Spanish-speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using both deductive and inductive approaches. Coded texts were grouped into domains and developed into a goal inventory for dementia care. Results Participants identified 41 goals for dementia care within five domains (medical care, physical quality of life, social and emotional quality of life, access to services and supports, and caregiver support). Caregiver goals included ensuring the safety of the person with dementia and managing caregiving stress. Participants with early-stage dementia identified engaging in meaningful activity (e.g., work, family functions) and not being a burden on family near the end of life as important goals. Participants articulated the need to readdress goals as the disease progressed and reported challenges in goal-setting when goals differed between the person with dementia and the caregiver (e.g., patient safety vs. living independently at home). While goals were similar among English and Spanish-speaking participants, Spanish-speaking participants emphasized the need to improve community education about dementia. Conclusions Patient- and caregiver-identified goals for care are different than commonly measured health outcomes for dementia. Future work should incorporate patient-centered goals into clinical settings and assess their usefulness for dementia care.

OBJECTIVES: To develop a process of goal-setting and measurement of goal attainment in a dementia care management program. DESIGN: Observational. SETTING: Dementia care management program in an urban academic medical center. PARTICIPANTS: Persons with dementia (N=101) and their caregivers; nurse practitioner dementia care managers (N=5). INTERVENTION: Specification of a personalized health goal and action plan and measurement of goal attainment using goal attainment scaling in a clinical care visit. MEASUREMENTS: Goal attainment at 6 and 12 months; focus groups of 5 dementia care managers. RESULTS: Eighty-four percent of participant goals were nonmedical, 47% were related to quality of life, and 29% were caregiver support goals. Eighty-eight percent of participants felt that the goal they set was meaningful and 74% that the goal-setting process captured something different from usual care, and 85% found the process helpful in planning for future care. At 6 months, 74% of dyads had achieved or exceeded their expected level of goal attainment. Dementia care managers felt that the goal-setting process improved their understanding of what was most important to the patient, helped set expectations about disease progression and care needs, and provided positive reinforcement when goals were accomplished and an opportunity for revision when goals were not met. CONCLUSION: Goal setting using goal attainment scaling can be incorporated into the care of persons with dementia to establish and attain person-centered goals. Research is needed to further develop personalized goal attainment as an outcome measure for dementia care.

An ecological niche modelling (ENM) approach was used to predict the potential feeding and spawning habitats of small (5-25 kg, only feeding) and large (>25 kg) Atlantic bluefin tuna (ABFT), Thunnus thynnus, in the Mediterranean Sea, the North Atlantic and the Gulf of Mexico. The ENM was built bridging knowledge on ecological traits of ABFT (e.g. temperature tolerance, mobility, feeding and spawning strategy) with patterns of selected environmental variables (chlorophyll-a fronts and concentration, sea surface current and temperature, sea surface height anomaly) that were identified using an extensive set of precisely geo-located presence data. The results highlight a wider temperature tolerance for larger fish allowing them to feed in the northern - high chlorophyll levels - latitudes up to the Norwegian Sea in the eastern Atlantic and to the Gulf of Saint Lawrence in the western basin. Permanent suitable feeding habitat for small ABFT was predicted to be mostly located in temperate latitudes in the North Atlantic and in the Mediterranean Sea, as well as in subtropical waters off north-west Africa, while summer potential habitat in the Gulf of Mexico was found to be unsuitable for both small and large ABFTs. Potential spawning grounds were found to occur in the Gulf of Mexico from March-April in the south-east to April-May in the north, while favourable conditions evolve in the Mediterranean Sea from mid-May in the eastern to mid-July in the western basin. Other secondary potential spawning grounds not supported by observations were predicted in the Azores area and off Morocco to Senegal during July and August when extrapolating the model settings from the Gulf of Mexico into the North Atlantic. The presence of large ABFT off Florida and the Bahamas in spring was not explained by the model as is, however the environmental variables other than the sea surface height anomaly appeared to be favourable for spawning in part of this area. Defining key spatial and temporal habitats should further help in building spatially-explicit stock assessment models, thus improving the spatial management of bluefin tuna fisheries